Nursing program, 180 credit points
Scientific methodology III, Bachelor thesis Course 17, 15 credit points
HK09 HT11
NURSING PANORAMA OF PATIENTS
WITH MUSCULOSKELETAL INJURIES
IN UGANDA USING NANDA AND NIC.
An Observational Study
Niklas Ergardt and
Clara Stenström-Kyobe
ABSTRACT
Background: Road traffic accidents are on the rise in low income countries and have a large
socioeconomic impact on Uganda. In Uganda, the nurse-patient ratio is 50-100 patients per nurse which is higher than in Sweden, and the patients’ next-of-kin are involved to assist with nursing care. Victims of road traffic accidents demand a lot of nursing care but contextual limitations give patients different opportunities for recovery. A common nursing language, as NANDA and NIC, aim to make communication more efficient; ease work for the staff and make the care better for the patients. Setting: The study was conducted at Mulago Hospital in
Kampala, Uganda. Method: Participant observation was used when observing the nursing care of 24 patients. Field notes were analyzed using manifest content analysis. Aim: The aim of this study was to identify the nursing panorama of patients with musculoskeletal injuries in their context. Result: The ratio between the ten most common diagnosis and interventions showed to be 222:59. The diagnostic span and the range of interventions varied according to if staff or next-of-kin performed the nursing of the patients. Conclusion: Using NANDA and NIC, revealed the next-of-kin in the study being responsible for nursing diagnoses and interventions.
INDEX
1 INTRODUCTION ... 1
2 BACKGROUND ... 1
2.1 Uganda ... 1
2.3 Nursing Situation in Uganda ... 2
2.4 Musculoskeletal Injuries ... 2
2.5 Nursing Panorama ... 4
2.6 Nursing Diagnoses and Interventions ... 4
3 PROBLEM AREA ... 5
4 AIM... 5
5 MATERIALS AND METHODS ... 5
5.1 Design ... 5 5.2 Setting ... 6 5.3 Sample ... 6 5.4 Data Collection ... 7 5.5 Data Analysis ... 8 6 ETHICAL CONSIDERATIONS ... 9 7 RESULT ... 10 8 DISCUSSION ... 25 8.1 Method Discussion ... 25 8.2 Result Discussion ... 28 8.3 Conclusion ... 32 8.4 Clinical Applications ... 32
8.5 Suggestion for Further Research ... 32
9 ACKNOWLEDGEMENTS ... 32
10 REFERENCES ... 34
11 APPENDIX I. ... 38
12 APPENDIX II. ... 39
1 INTRODUCTION
The workload of the registered nurse in Uganda is much larger than in Sweden. In Uganda, the nurse to patient ratio fluctuates between 1:50 and 1:100. Patients are reluctantly admitted to hospitals without a next-of-kin to aid with nursing care (Fournier, Kipp, Mill & Walusimbi, 2007). This nursing care structure caught our interest and is the reason why we chose to observe nursing diagnoses and nursing interventions in Uganda. NANDA (formerly the North American Nursing Diagnoses Association) and NIC (Nursing Interventions Classification) are evidence-based and standardized tools of nursing which validate this study by serving as a mode of reliability of the observations and results gained at Mulago Hospital in Kampala, the capital of Uganda. We determined nurses who work with patients with musculoskeletal injuries to be the area in which to conduct the observations; the context being the orthopedics department of Mulago Hospital.
2 BACKGROUND
2.1 Uganda
Uganda is a low income (World Bank, 2011) country of 236 040 km2, situated on the equator in East Africa (Libers VärldsAtlas, 2001). The country is neighbored by Kenya, Tanzania, Rwanda, Democratic Republic of Congo and South Sudan (Landguiden, 2011). Following the liberation from the colonial power of Britain in 1962, the country has suffered civil wars and harsh leaders, but has progressed towards a multi-party democracy (World Bank, 2010).
The official language in Uganda is English and the biggest of many local languages is Luganda (Briggs & Roberts, 2007). In 2010, the country had about 32.7 million inhabitants (World Bank, 2011), giving a population density of close to 139
people/km2. Most people work within agriculture (Briggs & Roberts, 2007), and only 13% of the total population live in urban areas (World Health Organization [WHO], 2010). According to the World Bank (2011), 75% of the adult country population is literate. The WHO concluded in a report from 2010 that the number of nurses and midwives countrywide is 13.1 per 10 000 inhabitants. In the same report, the
51 years for men in 2007. The three most common reasons for death, for both sexes and of all ages; are HIV/AIDS, malaria and lower respiratory infections (WHO, 2006).
2.2 Nursing Situation in Uganda
According to Helman (1994), the health care system of a country must be understood in relation to social aspects and religious organization. The Ugandan patients’ relatives administer a lot of the nursing care. Nurses cope with the shortage of staff by
instructing the next-of-kin to perform the required nursing procedures (Fournier, Kipp, Mill & Walusimbi, 2007). At Mulago Hospital, the nurse-patient ratio is 1:50 during day and 1:100 at night. Patients’ next-of-kin (attendants) are essential in the caring of patients. Health care in Uganda is expensive and the patient or attendants provide the patient with basic care such as food, bedding and medication. They may also need to pay for material costs such as syringes, intravenous fluids and basic care is always intended to be performed by attendants (Thompson & Cechanowiwicz, 2007).
Leininger (1995), claims that families in general have not been trained in professional nursing. In spite of this, research has shown the powerful impact families have on a family members’ physical health, at every stage of health or illness. Furthermore, studies confirm that the effect of a family members’ health/illness status is equal to that of the health of the family (Friedman, Bowden & Jones, 2003). The level of nurses’ education differs between different types of nurses. Most nurses are enrolled nurses which means certified but not registered. Then there are nursing assistants, many of which are training clinically to become enrolled nurses (Thompson and Cechanovicz, 2007).
2.3 Musculoskeletal Injuries
Between 1985 and 1995, Uganda had a 220% increase in licensed vehicles and between 1992 and 1996 the country had the highest increase in vehicle ownership in the East African region (Kobusingye, Guwatudde & Lett, 2001). Road traffic deaths are predicted to increase to become the third largest cause of Disability Adjusted Life Years (DALY’s) by the year 2020 (Demyttenaere et al., 2009). In a global perspective, 90% of deaths from road traffic accidents occur in low income countries (Hsia et al., 2010). These injuries are primarily occurring due to road traffic accidents. In Kampala, the capital of Uganda, musculoskeletal injuries account for 39% of all injuries. Mulago
Hospital orthopedics department is responsible for offering services for people with musculoskeletal injuries and receives 44 % of the individuals injured in road traffic accidents in Kampala (Naddumba, 2008). Demyttenaere et al. (2009), studied registries from 3778 patients at the casualty department at Mulago Hospital and found that the causes of the injuries were to 50% road traffic accidents, 15% blunt force, 10% falls, 9% stab wounds, 7% animal bites, 6% burns and 1% gunshot wounds. Orthopedic injuries are frequent results of blunt trauma like motor vehicle collisions, falls, crush injuries and auto/pedestrian collisions, but even gunshot and stab wounds can be included in orthopedic trauma categories (Bongiovanni, Bradley, & Kelley, 2005). Pre-hospital care is poor in Uganda. Out of 378 patients with severe musculoskeletal injuries admitted to the accident and emergency department, only 28% arrived within one hour. A large proportion of patients requiring circulatory stabilization, splints and intravenous infusions during pre-hospital care do not receive the appropriate treatment (Naddumba, 2008). The department of orthopedics at Mulago Hospital is responsible for offering services for patients with musculoskeletal injuries or disabilities. Apart from constructing equipment for people with disabilities, it has a health care provision through an out-patient clinic, in-patient care and specialized- and emergency surgery (Mulago Hospital, n.d.). The emergency surgical theatre in the orthopedics department runs daily and includes elective surgery three days a week. A separate theatre is open to infections two days a week. Every year, 1 400 surgeries are performed whereof on average 500 are emergency cases, 400 elective cases and 500 infection cases. Delay for surgery is common and mostly due to shortage of anesthesia, operating time and manpower (Naddumba, 2008).
The principles of orthopedic nursing are used when treating orthopedic patients. Orthopedics is the branch of medical science concerned with the preservation and restoration of the functions of the skeletal system (deWit, 2009). The overall nursing care is the same to the many different types of fractures. The restoration of bone alignment and immobilization until the bone has healed is essential to rehabilitate the patient to normal function or to help coping with disability. The early management of a non-life threatening injury is to clean wounds, but there are other essentials to keep under close observation. For instance, positioning and hemodynamic status is crucial to sustain good perfusion to all tissues, and important to avoid complications like
complications, preserving and training functions needed for Activities of Daily Life (ADL) (Kamp Nielsen, 2010).
2.4 Nursing Panorama
The nursing panorama was defined as everything evolving around the nursing diagnosis and interventions. Nursing diagnoses are followed by nursing interventions based on the diagnoses. The implementation of the nursing interventions is the actual doing (or delegating) and documentation of the nursing intervention and leads to the outcome in which visible results of the intervention can be seen (Wilkinson, 2007). The aim with nursing diagnoses is to assess the health situation of the patient, and the nursing interventions required to reach the desired outcome. When the correct nursing interventions are implemented, the patient will be relieved from the health problems (Wilkinson, 2007). The nursing diagnosis ensures the awareness of the individual needs of the patient, and facilitates choosing the correct nursing intervention (Florin,
Ehrenberg & Ehnfors, 2005).
2.5 Nursing Diagnoses and Interventions
NANDA and NIC are evidence based Western standardized vocabulary and
classification models, primarily developed in North America for usage in the nursing process as means to improve nursing (Johnson, 2005). The taxonomy of NANDA is based on diagnoses and statements with related characteristics in the form of signs and symptoms (Florin, Ehrenberg & Ehnfors, 2005). These nursing diagnoses are available to the use of the nurse within every professional specialty after assessing the needs of individuals, families or communities (Wilkinson, 2007). According to Thoroddsen and Thorsteinsson (2002) the nursing diagnosis has the potential of being a common language between nurses. According to the International Council of Nurses (2011) the use of a standardized language can facilitate staff communication and diminish
disinformation as well as plainly state the practice of the nurse. NIC is a classification of interventions that nurses perform. It focuses on nurse behavior unlike the nursing diagnose, which focuses on the patient. A nurse intervention is defined as any treatment, based upon clinical judgment and knowledge that a nurse performs to
enhance patient outcomes. The NIC interventions include direct and indirect care; that aimed at individuals, families and communities and that aimed at health workers. NIC describes the domain of the nurse, but some interventions can also be executed by those who are not health care providers. NIC can be used in all settings and within all care specialties (Johnsson, 2005). Both NANDA and NIC are meant to be useful within all the world’s cultures, though to our knowledge, it has not yet been evaluated in Uganda.
3 PROBLEM AREA
Uganda has long been of interest on both a private and an intellectual level and given our future career, the experience of working in a low-income country will be useful. Musculoskeletal injuries are similar regardless of the context but in Uganda these are on the rise and a great socioeconomic problem. Even if the nursing panorama is dramatically different between a low income - and a high income setting it is relevant to research the differences and/or similarities between these settings.
4 AIM
The aim of this study is to identify the nursing panorama of patients with musculoskeletal injuries in the context and habitat of the patients and the staff.
5 MATERIALS AND METHODS
5.1 Design
This study was an empirical observational study with a qualitative approach.
Pilhammar Andersson (1996) explains the participant observer as an identity of which the ones observed are aware. The participant observer needs to be active through
observations, formulating and asking questions and again observing. The strategy of the participant observer can be to uncover what the observed participants take for granted in a specific situation (French, 2005).
5.2 Setting
The observations took place at the orthopedic ward, ward 7, at Mulago Hospital in Kampala, Uganda. This ward received stable emergency cases and elective orthopedic cases. It was common that a long time had passed between the time of the accident and the arrival of the patient to ward 7. The reasons for this were mainly three; 1) patients had first been admitted to an emergency orthopedic ward due to their unstable
condition, 2) patients had first gone to traditional healers before coming to the hospital, or 3) patients had not been admitted earlier due to lack of beds or low blood
hemoglobin. Ward 7 consisted of 50 beds, divided into a male, and a female and children’s section. Each section was a single rectangular room with an isle through the middle and with beds along the walls on each side. The ward had a postoperative section of eight beds as well as six side rooms. Side rooms were sectioned areas with walls, half way to the roof and doors for patient’s privacy. The side rooms came with an extra renting fee. Patients were said to stay at the ward an average of maximum three weeks. Many patients had splinted extremities. An example of splints is the non-operative invasive method to keep the fracture site stable while letting it heal. This splint consists of a metal funnel around the extremity nailed into the bone on the proximal side of the fracture site. On the distal side of the fracture site the extremity is either tied in place or nailed. If needed, weights can sometimes be added to the distal part to improve appropriate healing.
5.3 Sample
The number of patients observed was the total of patients who fulfilled the following inclusion criteria: They were victims of road traffic accidents, had at least one
musculoskeletal injury and were admitted to the orthopedic ward 7 at Mulago Hospital. The attendants of the patients were also included in the sample. The patients were of both sexes and of an age ranging from 18 to 65 years old. The number of staff members observed was defined as those responsible for the selected group of patients. Inclusion criteria of the observed nurses were that they understood and spoke English. They had to be able to translate to the patient and explain the content of the study, and what the observer was doing there.
The nurse-patient ratio was 6:43 during the time when the observations took place, during the morning shifts (8 a.m. – 5 p.m.). During evening shifts (2 p.m. - 8 p.m.) and night shifts (8 p.m. – 8 a.m.) the nurse-patient ratio was 1:43.
Upon observation, 19 men and 5 women had suffered a road traffic accident within two years as main reason for admittance (see table 1). None of these 24 patients declined being part of the study.
Table 1. Table of patients at Mulago Hospital, ward 7 and number of patients fitting the inclusion criteria, during the
study period in October 2011.
Total number of patients at ward 43 Sex Male: 31 Female: 12 Age 0-17 18-65 65+ 0-17 18-65 65+ Number of patients 0 31 0 5 7 2
Cause of injury Road
traffic accident: 19 Other: 12 Road traffic accident: 5 Other: 2 Number of patients fulfilling the inclusion criteria 19 5 5.4 Data Collection
Transcultural nursing is based on humanistic and scientific knowledge. The scientific method is to study human and nursing care behavior, but the personalized humanistic approach should not be neglected in order to obtain the holistic cultural care
phenomena. According to Leininger (2002), transcultural nursing means discovering why differences or similarities exist between cultures through the perspective of care, health, illness and death.
Upon first meeting the patients, attendants and nurses, they were informed concerning the aim of the study and that information in the study would not be traceable to a specific patient; that the right to withdraw from the study and that participation in the study would not change their access or level of care. The data was then collected through field notes, using a protocol to assure proper noting (Appendix I.). Both Pilhammar Andersson (1996) and Polit and Beck (2008) support the idea of a note structure, since observations should not be memorized for more than one hour (Polit & Beck). The days of observations were ten, divided into two sections with five days apart to minimize the risk of observing the same patients throughout the data collection period.
This study was a participant study of investigation. The nursing panorama was
observed and documented through field notes. The observations consisted of diagnoses and interventions carried out by the staff or the patients’ attendants. Journals were used as a complementary source of information of each patient. The diagnoses and the originators of the diagnoses were clarified with the participation of the patient, the attendants and/or the staff. Upon observing a new patient, this clarifying procedure was repeatedly performed.
5.5 Data Analysis
Field notes were analyzed using manifest content analysis. According to Graneheim and Lundman (2004), content analysis is a method with the purpose to organize and structure the collected data. The content analysis of an observation means to divide observational notes into meaning units and condense the meaning units into
descriptions close to the content; the manifest content.
The field notes differentiated if the diagnoses and interventions were performed by patients, attendants or staff. The manifest content described diagnoses which were compared to the NANDA taxonomy in order to deduct the observed NANDA diagnosis. We also linked diagnoses and interventions or indeed reviewed them unlinked if they were not found in the NANDA or NIC. If observed diagnoses and interventions were not found in the NANDA or NIC, they were still imbedded as results of the research and brought up to discussion. The NANDA and NIC structures are taxonomies based on research and served to help the researchers avoid caprice
based on own nursing diagnose/intervention experience. The diagnoses that were set by attendants were confirmed by observing their interventions and then by briefly
questioning the attendants on why they intervened. Hence, the attendants themselves gave the diagnoses to their own interventions in almost all cases.
6 ETHICAL CONSIDERATIONS
Because of ethical considerations, and before initiating the study, a letter was sent to the International coordinator at Mulago (appendix II). The international coordinator added her consent and referred us to the head of department who approved and put us in touch with the chief nurse at ward 7. After the acceptance of chief nurse, the study was explained to the staff of the ward. All patients and next-of-kin received both written and oral information about the study. The written information was in English (appendix I), and the oral in either English or five other Ugandan languages represented amongst the staff at the ward. The patients were, while being informed, given time for questions about the study. No patient who fitted the inclusion criteria declined
participation in the study. One patient with a neurological impact was first informed, then observed and then again informed. This was due to his condition of amnesia.
7 RESULT
Table 2. Ten most common diagnoses under NANDA class, who executed the diagnosis and number of times it
occurred during the study period September 2011.
Table 3. The ten most common NIC interventions in the study who executed the diagnosis and number of times it
occurred during the study period September 2011.
.
Interventions according to NIC Occurrence Executed by whom (occurrence)
Medication management 12 Nurse (10), Doctor (1), Attendant (1)
Teaching; individual; prescribed activity/exercise
10 Physiotherapist (5), Nurse (4), Nurse/doctor (1)
Wound care 9 Nurse (8), Doctor (1)
Pain management 6 Nurse (6)
Self-care assistance: Feeding 6 Attendant (6)
Self-care assistance 5 Attendant (5)
Exercise therapy 4 Physiotherapist (2), Patient (1), Doctor (1)
Positioning 3 Doctor (2), Nurse (1)
Exercise promotion 3 Nurse (2), Doctor (1)
Bleeding reduction 3 Nurse (2), Attendant (1)
The result will be displayed starting with the part of the attendants in the studied setting and continue regarding fractures, followed by the findings under major NANDA diagnoses and anemia. In table 2 and 3 (above) the most frequent interventions and diagnoses are displayed. These will be described further in the final part of the result.
7.1 Attendants
Attendants consisted of close family, siblings and friends and were both male and female. For the admitted patients, the hospital provided a bed with a mattress, in most cases a mosquito net, a drip holder, basic medication and a common electric kettle. The patient/attendant had to provide food, water and ways of cooking, mats/mattresses for attendants to sleep on, pillow for the patient, beddings, basin and bucket. The patient or the patient’s attendants made the patient’s bed, took care of elimination, vomiting,
NANDA class NANDA Diagnose Occurrence Executed by whom (occurrence)
Activity/exercise Impaired Physical mobility 24 Observer (22) Doctor (2) Risk for disuse syndrome 23 Observer (21) Doctor (2) Physical injury Impaired skin integrity 23 Observer (21), Nurse (2) Impaired tissue integrity 23 Observer (21), Nurse (2) Ineffective protection 23 Observer (22) Nurse (1) Risk for injury 21 Observer (20) Doctor (1) Risk for peripheral neurovascular
dysfunction
24 Observer (23) Doctor (1)
Infection Risk for infection 21 Observer (22), Nurse (1) Doctor (1) Self-care Dressing self-care deficit 20 Observer (18), Attendants (2)
washing of clothes and beddings, cooking and eating food as well as bathing and brushing teeth.
The diagnoses and interventions carried out by attendants are displayed in table 4 and 5 and will be explained below.
Table 4. NANDA diagnoses set by attendant and number of times occurred.
Table 5. NIC interventions executed by attendants
The diagnose self-care deficit: feeding was always followed by the corresponding intervention, self-care assistance: feeding. These interventions were executed by the same attendants that set the diagnosis. This pattern continued with toileting-, bathing- and dressing self-care deficits. The risk for compromised human dignity diagnosis was set by attendants helping their patient with privacy when eliminating. The diagnosis was followed by the intervention emotional support. This was observed as a specific need of the patient and it was provided by the attendants. The ward had two paravans for these occasions but they were seldom used. The intervention temperature
regulation was executed by attendants to a patient who suffered from anemia and a
decrease in body temperature. The scenario involved the attendants putting a blanket on the patient and was preceded by the diagnosis ineffective thermoregulation. Changing of bed sheets was only observed once and set as environmental management: comfort. This intervention was seen as an intervention towards self-care deficit. The changing of bed sheets was not performed every day.
Feeding self-care deficit (8) Toiletting self-care deficit (4) Dressing self-care deficit (2) Bathing self-care deficit (2)
Risk for compromised human dignity (1) Interrupted breastfeeding (1)
Ineffective thermoregulation (1)
Self-care assistance: Feeding (7) Self-care assistance: Toiletting (4) Self-care assistance: Dressing (2) Self-care assistance: Bathing (2) Self-care assistance: Hygiene (2) Temperature regulation (1) Surveillance (1)
Aspiration precautions (1)
Environmental management: Comfort (1) Bleeding reduction (1)
The interventions surveillance and aspiration precautions were results of a feeding problem which involved a patient with facial paralysis. The attendants suggested small portions of soft food and fed the patient keeping an eye on the swallowing. Bleeding
reduction involved attendants assisting the patient with elevation of limbs. Table 6
describes how the nursing panorama in the study counted on attendants to be able to perform nursing and care, both diagnostic and through interventions in order for their next-of-kin patient to survive the hospital stay.
Table 6. Anemic patient with external bleeding and impaired mobility.
Observation Manifest content Meaning units Nursing code Category Executed by whom Observed interventions (specify by whom) Analgesics (nurse) Elevation of limbs (attendants), assistance to sit up (attendants) while eating, and eliminating. Nurse: Analgesics Next of kin: Elevation of limbs, assistance to sit up, eating and elimination . Medical pain treatment Medication management Wellbeing: intervention Nurse Assisting pt positioning, eating and elimination. Bleeding reduction Cardiovascular/ pulmonary response: Intervention Attendants Feeding Nutrition: Intervention Self-care assistance: Toileting. Self-care: Intervention 7.2 Lacking attendants
The most interesting findings were made in relation to patients who were admitted and lacked attendants. The standard at Mulago Hospital was that the patient was responsible for the costs and the attendants necessary to sustain the care needed. This fact was known by the patients. In spite of this, one patient were admitted well-dressed but with a broken upper extremity. The patient claimed to be an orphan without any attendants, a scenario which were perceived impossible by the observer, given the appearance of the patient. The patient was too disabled by the injuries to have been able to achieve the appearance single handedly. However, no diagnostic findings could conclude the peculiarity of this patient and the diagnostic span resembled other patients with fractured extremities.
Another interesting finding regarded a patient who could not prepare for surgery due to the lack of attendants. The patient was stuck in ward 7 but in need of nutritional boost and surgery. A second patient in similar condition could not pay for the final x-ray before being discharged and therefore also remained at the ward. Yet a third patient managed to borrow the attendants from a fellow patient to be able to go to a check-up
x-ray. This patient also lacked money but was able to receive hospital funds in order to be x-rayed and transported home. It turned out this patient shared culture and
community with the borrowed attendants as well as the staff who provided the special treatment. This only occurred once with the patients lacking attendants and money (see table 7). This was perceived as somewhat corrupt but the action in itself gave the diagnosis readiness for enhanced community coping due to the existing willingness of meeting the demands of the health care situation at Mulago Hospital and its care receivers. The intervention was executed in collaboration; one nurse identified the risk and a social worker together with a senior consultant supported the nurse /patient in making a decision that managed the health of the patient and the work of the nurse. For the patients who lacked attendants and were stuck in the ward the scenario was
analyzed as ineffective community coping. These patients only received interventions in the form of analgesics. One of the patients also received pain management in the form of counseling when the nurse explained the etiology of the pain and the effect the pain had.
Table 7. Patient lacking money and attendants, borrowing attendants and receiving financial help.
MEANING UNIT CODE CATEGORY OBSERVED/INTERVEENED
BY WHOM
Nurse to senior consultant who permits free xray and transport. Patient borrows next of kin. Readiness for enhanced community coping.
Coping responses Observer
Decision making support. Health management: Intervention Community coping: Intervention Social worker/nurse/senior consultant. Community health development Risk identification Readiness for enhanced self-health management.
Health management. Observer
7.3 Recent fractures
The difference in diagnostic findings between old and recent fractures was peculiar. One would assume that the difference in number of diagnoses would be greater. However the diagnostic findings were similar in quantity bur varied in physiological significance. In the case of patients with old fractures, fractured areas had been splinted and gave diagnoses according to the physiological condition that occurs when metal has been nailed through tissue and into the bone of the patient (see table 8). A recent fracture had similar findings since bone and tissue had been damaged through recent
road traffic trauma. During the study only two patients had fractures that had occurred within a couple of days upon observation. Many patients with old fractures were still in a condition that resembled that of a patient who recently had suffered a road traffic trauma, mainly due to anemia without successful treatment. The difference in diagnostic findings between an old and a recent fracture are stated in figure 1 and 2.
Fig 1. NANDA categories with NANDA diagnoses that were set on old fractures.
Fig 2. NANDA diagnoses associated with recent fractures and additional diagnoses when recent fracture in italics. OLD FRACTURES
Activity/exercise: Risk for disuse syndrome Impaired physical mobility
Physical injury: Risk for peripheral neurovascular dysfunction Ineffective protection Impaired tissue integrity Impaired skin integrity Risk for injury Self-care: Bathing self-care deficit Dressing self-care deficit Toileting self-care deficit Infection: Risk for infection Activity/exercise: Risk for disuse syndrome Impaired physical mobility
Physical injury: Risk for peripheral neurovascular dysfunction.
Ineffective protection Impaired tissue integrity. Impaired skin integrity Risk for injury.
Risk for bleeding
Self-care: Bathing self-care deficit Dressing self-care deficit Toileting self-care deficit Infection: Risk for infection RECENT FRACTURES
Cardiovascular/pul-monary responses: Risk for shock
Table 8. NANDA diagnoses following splints.
7.4 Femur fractures
Among the patients with femur fractures many had had initial anemia which interestingly enough had yielded albeit the shortage of blood. Out of the seventeen patients with single or multiple femur fractures, fourteen had suffered closed fractures on the femur. Three patients had suffered an open femur fracture. These patients stood out due to their various injuries; one patient also had a closed humerus fracture which was being managed in a cast. However the arm was dysfunctional with post-operative nerve damage. A second patient had multiple closed fractures on tibia, mandible and parasymphase. The third patient had recovered from severe trauma and was the only patient during the study who was admitted to hospital via ambulance. This patient also had the widest range of injuries. The patient was operated 39 days prior to the
observation. Medical conditions as the one above were noted with interest but not analyzed further, regarding the historic injuries. Only current states were analyzed. Two patients had multiple closed fractures on femur. One of these patients had multiple femur fractures bilaterally, a stabilized open book fracture and an initially acute
anemia. This patient was walking with the help of the attendants. The second patient had, except for multiple fractures on femur, multiple fractures on tibia and humerus, abdominal- and chest pain and was severely anemic.
7.5 Self-Care Deficit
All patients with fractures were diagnosed with bathing-, dressing- and toileting
self-care deficit except one patient with a chronically disabled elbow and a fractured arm.
This patient only needed assistance with dressing and washing of the body. The patient stood out due to having proceeded daily routines with a fractured arm for three months.
SPLINTS
Risk for peripheral neurovascular dysfunction Risk for disuse syndrome
Risk for injury Ineffective protection Impaired skin integrity Impaired tissue integrity Risk for infection
These circumstances had forced the patient to return home and self-heal. Ten patients were diagnosed with feeding self-care deficit because this applied to the altered ability resulting from fractures on upper extremities and in one case a facial paralysis. The facial paralysis created loss of vision and double vision and an aspiration risk whenever feeding. The patient was trained by a doctor to make the nerves restructure. This was done with a balloon and a small stick. Unfortunately the details regarding this treatment were not uncovered. The attendants of the patient were some of the few attendants who actually took initiative to suggest something to the nurse. This was usually considered audacious by the staff. Feeding self-care deficit was defined as the inability to prepare and eat food.
7.6 Impaired physical mobility/Risk for disuse syndrome
The impaired physical mobility- and risk for disuse syndrome were two of the most common diagnoses among the diagnostic findings. These diagnoses continued with all patients.
Table 9. Observed NANDA diagnoses under the class; activity/rest, with following interventions. Occurrence is the
total number of the time/times the intervention was observed during the study period.
NANDA Class: Activity/exercise
Nursing diagnose (occurrence) Interventions (occurrence) Intervened by whom (number of times in total)
Impaired physical mobility (24) Exercise promotion (2)
Exercise promotion: stretching (4) Teaching: individual (6)
Teaching: prescribed activity (4) Exercise therapy: muscle control (1) Exercise therapy: ambulation (1)
Nurse (2)
Doctor (2), nurse (1), patient(1), Nurse (2), Physiotherapist (3), nurse/doctor (1)
Physiotherapist (2), Nurse (2) Physiotherapist (1)
Patient (1) Risk for disuse syndrome (24) Exercise promotion (1)
Exercise promotion: stretching (4) Teaching: individual (6)
Teaching: prescribed activity (4)
Nurse (1)
Nurse (2), patient (1), doctor (1) Nurse (2), Physiotherapist (3), nurse/doctor (1)
Physiotherapist (2), Nurse (2) The intervention exercise promotion was set as an adequate intervention to both diagnoses in table 9. In the observed situation exercise promotion was a degrading verbal treatment of a patient by a nurse. The patient had a stabilized open book fracture.
Risk for compromised human dignity was set to this patient following the verbal
treatment of the staff.
The intervention exercise promotion: stretching was ordered by doctors. The situations consisted of bedridden patients letting their legs stretch from the side of the beds to increase tissue perfusion.
Teaching: prescribed activity was conducted following one facial paralysis, one
walking exercise and two bedridden patients. These were ordered by doctors and physiotherapists.
7.7 Risk for peripheral neurovascular dysfunction.
Table 10. Observed NANDA diagnosis under class: Physical injury with following NIC interventions NANDA Class: Physical injury
Nursing diagnose (occurrence) Interventions (occurrence) Intervened by whom (number of times in total)
Risk for peripheral
neurovascular dysfunction (24)
Exercise promotion (2)
Exercise promotion: stretching (4) Neurologic monitoring (1)
Circulatory care: mechanical assist devise (1)
Bleeding reduction (3) Positioning (2)
Teaching: prescribed activity (4) Exercise therapy: muscle control (1)
Nurse (2)
Doctor (2), nurse (1), patient (1),
Doctor (1) Physiotherapist (1) Nurse (2), Attendants (1) Nurse (1), physiotherapist (1) Physiotherapist (2), Nurse (2) Physiotherapist (1)
The primal etiology for risk for peripheral neurovascular dysfunction during the study was perceived as concerning sensory and/or motoric function in the fractured extremity. Two other etiologies were however noted; tissue perfusion; coordinated movement; and sensory/motor function. The interventions are shown in table 10. One patient had disabilities concerning all three etiologies above, namely a swollen and cold extremity which was intervened with neurologic monitoring by a doctor to diagnose the medical condition. A physiotherapist executed exercise therapy: muscle control and circulation
care: mechanical assist devise. Circulation care: mechanical assist devise consisted of
a special splint implemented to prevent swelling and additional nerve damage. The interventions in table 10 were in all implemented to increase tissue perfusion, coordination and heal damaged nerves. Teaching: prescribed activity/exercise was primarily intervened with four patients to coordinate muscular movement and reduce joint stiffness.
Exercise promotion was intervened as a way to get a patient up and going. The scenario
was preceded by a nurse calling the patient lazy. This was diagnosed as exercise
promotion because the etiology of the nurses’ exhortation was to the better of the
patient, however verbally degrading. Exercise promotion: stretching was intervened as a way to minimize a declining neurological status. This was done with four patients and involved the patients stretching their tendons/muscles by letting the legs stretch off the side of the bed. Positioning was intervened with two patients to enhance peripheral
tissue perfusion and consisted of varied placement of body and limbs. Bleeding
reduction was intervened with the same two patients as a way to limit blood loss. These
interventions were interesting findings as they were carried out by attendants on their own initiative with one of the patients (see patient 2 in table 11). The equivalence by staff was carried out on a later occasion and did not influence the attendants under patient 2.
Table 11. Patients intervened by same interventions by staff and attendants.
Patient 1 Observation Manifest
content
Meaning units
Nursing code Category Executed by whom
Observed interventions (specify by whom)
Blanket on patient (next of kin) Ringer acetate (nurse/dr) Attendant: Blanket on patient. Blanket on patient.
See above attendant
Nurse/doctor: Ringer acetate Drip to patient. Fluid/electrolyte management. Fluid balance: Intervention. Nurse/ Doctor After switching nurses
(lunch time) the new one gave pt Pethidine i.m. to reduce pain as well as improved bandaging to stop bleeding, Pillow under right foot and head slightly downwards to decrease bleeding. Nurse: Pethidine i.m. Analgesics to pt. Medication management Wellbeing: Intervention Nurse Improved bandages to stop bleeding. Stopping blood loss.
Wound care Physical injury: Intervention
Nurse
Pillow under right foot, head downwards to decrease bleeding. Body adjustments to decrease bleeding. Bleeding reduction Physical injury: Intervention Nurse Positioning Patient 2 Observed interventions (specify by whom) Analgesics (nurse) Elevation of limbs (attendants*), assistance to sit up (attendants) while eating, and eliminating. Nurse: Analgesics Next of kin: Elevation of limbs, assistance to sit up, eating and elimination. Medical pain treatment Medication management Wellbeing: intervention Nurse Assisting pt positioning, Bleeding reduction Cardiovascular /pulmonary response: Intervention Attendants Positioning Physical injury: intervention Eating Feeding Nutrition:
Intervention and elimination. Self-care assistance: Toileting. Self-care: Intervention
7.8 Risk for injury/Ineffective protection
The nature of the risk for injury diagnosis was in general considered as a severity of physical injury which risked further injury. The diagnosis was applied on impaired
sensory function status, deficient balance and deficient risk control. This was due to the overall status of being relatively recent trauma patients. With two patients the
indignation of the staff resulted in the diagnosis risk for injury: staff. This diagnose is non-existing within the NANDA taxonomy. The diagnosis was set following a situation where one nurse neglected wound care due to annoyance with the wound care duty, and in the second situation consisted of a nurse claiming a patient to be pain controlled although the patient was in severe pain and screaming for analgesics. Risk for injury was set to 23 patients. One patient was deemed in too stable condition to receive the diagnosis. This patient was fully functional except for a one year old chronic
dislocation of elbow and a three month old fracture.
The diagnosis ineffective protection was set due to the lack of risk identification and the workload of the nurses. Most observed interventions were generic in relation to the diagnoses stated in table 12. The stated interventions are therefore those performed with consideration to risk circumstances where staff/attendants expressed concern about the unstable conditions of the patients. This was common with attendants but not as common with staff. In table 12 it is on the other hand the staff that is overrepresented as we have stated the interventions that demanded clinical practice out of the ordinary.
Table 12. NIC Interventions following physical injury NANDA diagnoses; risk for injury and ineffective protection. NANDA Class: Physical
injury
Nursing diagnose (occurrence)
Interventions (occurrence) Intervened by whom (number of times in total)
Risk for injury (24) Ineffective protection (24)
Decision making support (1) Environmental management (2) Bleeding reduction (3)
Community health development (1) Exercise promotion (5)
Risk identification (2) Reality orientation (1) Surveillance (1)
Social worker/nurse/senior consultant (1) Attendant (1), Nurse (1)
Nurse (2), Attendant (1)
Social worker/nurse/senior consultant (1) Patient (1), Nurse (2), Doctor (2)
Doctor (1), Social worker/nurse/senior consultant(1)
Observer (1) Attendant (1)
7.9 Impaired skin integrity/Impaired tissue integrity
The diagnoses impaired skin integrity and impaired tissue integrity were set as results of trauma wounds, invasive operative interventions or splints. Where a wound was present the interventions were implemented to heal the wounds by positioning and
bleeding reduction (see table 13). Wound care was intervened with nine patients. Skin surveillance preceded wound care on two occasions where the need for wound care
was not obvious without inspecting the wounds on the patients. Medication
patients. Fluid/electrolyte management in the form of an administered glucose drip was given to a patient who was breastfeeding an infant. This patient had had a skin
transplant to a crushed ankle which resulted in the intervention skin care: donor site.
Table 13. NIC Interventions following physical injury diagnoses impaired skin integrity and impaired tissue integrity. NANDA Class: Physical injury
Nursing diagnose (occurrence) Interventions (occurrence) Intervened by whom (number of times in total)
Impaired tissue integrity Impaired skin integrity
Skin surveillance (2) Medication management (2) Wound care (9)
Bleeding reduction (2) Skin care. Donor site (1)
Fluid /electrolyte management (1)
Nurse (2) Doctor (2) Nurse (9) Nurse (1), Attendants (1) Nurse (1) Nurse (1)
7.10 Risk for infection
Out of the patients diagnosed with risk for infection (24), one was intervened with a blood test. In this case the patient had an obviously infected wound. Two other patients also had obviously infected wounds during the study period and were intervened with
wound care and skin care: donor site.
7.11 Anemia
It was observed that many patients were anemic with different etiologies than blood loss. Many medical conditions resulted in anemia due to an altered state of blood components due to malaria or other parasitic tropical disease. These forms of anemia were, with most patients, a hint rather than a diagnosis and enhanced the ineffective
protection and risk for injury diagnostics. Nine patients with fractures also suffered
anemia following road traffic trauma, which either had gone back to stabilized circulatory status or was present upon observation. All these patients had suffered femur fractures. Six patients were suffering from anemia with varied severity during the study period. Two of these patients had experienced the road traffic accident a couple of days prior to the observation and were considered patients with recent fractures. These two patients suffered from severe anemia. One of the patients was in a state of dying, according to the present doctor, due to the anemia accompanied with jaundice, edema, dehydration and cyanosis. The second patient was booked on
receiving three units of blood and awaiting surgery that could not be performed before the patient had sufficient blood hemoglobin. At the time, the three units of blood was the total blood stock of the hospital blood bank. The lack of blood in the hospital blood
bank was diagnosed as ineffective community coping concerning four patients. With the two patients who suffered severe anemia, the staff stated that nothing could be done for the patients and complained about the shortage of blood. In one situation the anemia and lack of blood were followed by medication management as an intervention to boost the blood production. Why this only occurred once was unclear to the observer.
Anemia and fractures created overlapping diagnoses. Patients with these overlaps were diagnosed only once with the same diagnose, even if the diagnose had two different etiologies.
Fig 3. NANDA diagnoses that were set on anemia. Similarities between fractures and anemia are marked in italics.
The diagnosis risk for ineffective self-health management was set to patients with anemia due to lack of knowledge regarding nutritional requirement for this medical condition and the situation at Mulago Hospital, where attendants provided nutrition. One patient with anemia was intervened with nutritional counseling by a doctor and a nurse. This meant being told to eat iron rich food and drink a lot to cure dehydration.
Infection: Risk for infection
Anemia Cardiovascular/pul-monary response: Activity intolerance Fluid balance: Risk for imbalanced fluid volume
Risk for electrolyte imbalance.
Nutrition:
Imbalanced nutrition: Less than body requirements
Health management: Risk for ineffective self-health management
Physical injury: Ineffective protection Risk for injury Risk for bleeding
Fig 4. Additional NANDA diagnoses to severe anemia, marked in italics.
One patient had severe anemia due to internal and external bleeding. The health of the patient declined due to the lack of blood in the hospital blood bank. Staff complained about the hopeless scenario with the term: “This is Uganda”. The interventions in this case consisted of bleeding reduction carried out by attendants and medical treatment by doctor/nurse to boost blood (see table 14).
Infection: Risk for infection
Anemia, severe
Cardiovascular/pul-monary response: Activity intolerance
Risk for shock Risk for decreased cardiac tissue perfusion Risk for ineffective gastrointestinal perfusion Risk for ineffective renal perfusion Risk for impaired oral mucus membrane Risk for ineffective cerebral tissue perfusion Fluid balance: Risk for imbalanced fluid volume
Risk for electrolyte imbalance.
Nutrition:
Imbalanced nutrition: Less than body requirements
Health management: Risk for ineffective self-health management Physical injury:
Ineffective protection Risk for injury Risk for bleeding
Table 14. Analysis of patient with severe anemia.
Observation Manifest content Meaning
units
Nursing code Category Whom
Observed interventions (specify by whom) Analgesics (nurse) Elevation of limbs (attendants*), assistance to sit up (attendants) while eating, and eliminating.
Nurse: Analgesics Next of kin: Elevation of limbs, assistance to sit up, eating and elimination.
Medical pain treatment.
Medication management Wellbeing: intervention Nurse Assisting pt positioning, eating and elimination.
Bleeding reduction Cardiovascular/ pulmonary response: Intervention Attendants Feeding Nutrition: Intervention Self-care assistance: Toileting. Self-care: Intervention Reflections Medication prescribed to patient includes analgesia and blood-boosting medication. All personnel involved in patient complain of unfortune in lack of blood in blood bank, but also state that “this is Uganda”.
Medication prescription to boost blood and analgesics. Personal complaining over lack of blood in blood bank. Medical pain- and anemia treatment
Medication management Cardiovascular/ pulmonary responses: intervention Nurse Lacking blood bank. Ineffective community coping. Coping responses
7.12 Ineffective community coping
Table 15. Etiology to ineffective community coping.
Diagnose Etiology
(occurrence)
Executed by whom. Resulting
diagnose/intervention Intervened by whom. Inneffective community coping Lacking essential equipment when training facial muscles.
Doctor Teaching: Individual Physiotherapist Teaching: Prescribed
activity/exercise No follow up on
previous inability to urinate
Observer Toiletting self-care deficit Attendants Emotional support
Self-care assistance: toileting
Lacking blood bank (4)
Doctor/nurse/observer Medication management Nurse Teaching individual.
Nutrition management. Attendants Lack of analgesics Nurse Medication management Nurse Patient lacking
attendants
Nurse/observer See fig 20 - Wound wrappings faulty Doctor - - Patient awaiting hospital bed. Nurse - -
Ineffective community coping was set as a diagnosis with eight patients and was, among
other factors, a result of deficient equipment. This was perceived as frustrating for the staff in most cases. The waiting list for a hospital bed was one etiology for ineffective
community coping. This was explained as a common problem by the nurses. The
deficient follow up on a patients’ ability to urinate was commented by a nurse as a responsibility of the attendant. This was also an etiology for ineffective community
coping but initiated the attendants to help with elimination and privacy. The lack of
blood only resulted in interventions with one out of four patients. The lack of analgesics resulted in medication management of an inferior type of analgesia. No interventions were executed following faulty wound wrappings or the shortage of hospital beds.
7.13 Acute pain
Fifteen patients were diagnosed with acute pain. The patients either suffered from pain following a recent injury or pain following an operation. Ten patients with acute pain were treated with medication management in the form of analgesics, given by a nurse in nine situations and by attendants in one situation following a medication deficit at the hospital pharmacy. This situation involved attendants buying medication from a separate pharmacy. With one of the patients pain management in the form of
counseling was combined with medical management. In four situations, patients did not
receive analgesics. One of these patients denied analgesics, the rest were denied analgesics due to shortage of medicine or nurses’ attitudes.
7.14 Most common diagnoses/interventions
Mulago hospital had not implemented the NANDA taxonomy during the study period. The diagnoses were set primarily by the observer. This did not mean that staff or attendants never realized the etiology of the diagnoses, only that the observer was not there to see proof of their realization. In many situations it was obvious that attendants and staff realized the etiology of various diagnoses but it was not always clear who had been the executioner of this knowledge. Where staff or attendants set the diagnoses it was observed that they had informed the patient and/or attendants or observer of the medical condition. The ten most common diagnoses resembled the diagnostic findings with fractures.
Medication management consisted primarily of the maintenance and administration of
analgesics. On one occasion antibiotics was the medical treatment as a result of a blood test following an infected wound. This was done with one of the three patients with infected wounds. Blood boosting medication was used as an alternative to blood transfusion with one out of seven patients with anemia. Another one of these patients
was booked for a blood transfusion. Teaching; prescribed activity/exercise and
teaching; individual was primarily intervened due to road traffic trauma to maintain
and restore perfusion and mobility. The ratio between the ten most common diagnoses and the ten most common interventions was 222 diagnoses to 59 interventions during the study period.
8 DISCUSSION
8.1 Method Discussion
Because of the researchers’ connection to Uganda and to Mulago Hospital the decision to conduct the observational study seemed interesting as well as practical. The
orthopedic ward was chosen because of its category of patients who were assumed to be mainly road traffic victims, have many diagnoses and need a lot of assistance in daily life. This also showed to be the case. The emergency orthopedic ward was not chosen due to inaccessibility.
The aim of the study was to identify the nursing panorama of the patients with musculoskeletal injuries in Uganda. This was done according to the classification systems of NANDA and NIC. Participant observation was chosen because the aim was to identify NANDA and NIC in the participants’ natural habitat. To prevent the same patients from being observed multiple times, the observations were divided into two periods with five days apart. This showed to be efficient as new patients had arrived at the ward the second week. The observer quickly became a natural part of the team at the ward, though was mainly left to observe without participating. The few times of participation in actual nursing were not included in the result, as Pilhammar Andersson (1996) states that the more an observer participates in the observations, the more the observation is likely to be distorted.
Observational notes and information from patients’ journals was written down as field notes following a protocol parallel to the observations as “notes of learning”. This was the common way at the ward to note information, all professions noted in this way, and it was therefore also seen as a way to blend into the context and setting at the ward. As soon as possible after the observation, the notes were extensively completed with information. The way of noting immediately to the observations minimizes the risk of losing information or it being misinterpreted due to other impressions (Polit & Beck,
2008). Following a field protocol enabled the observer to focus on the observation as well as to receive all needed information. The information on the protocols was analyzed using manifest content analysis. This way, it is possible to systematize knowledge of characteristics (Olsson & Sörensen, 2007). In this study, it meant the systematizing of the characteristics of the nursing diagnosis and interventions. Content analysis is an open method which allows the researchers to explain in a concrete way how they have performed the coding, and which is flexible in its sense of being applicable to many different kinds of unstructured information (Bryman, 2011). The risk of the researcher/coder interpreting from its own pre-understanding, though, is great. The coding of diagnosis from observations could have been affected by the researchers’ lack of medical knowledge as we are still nursing students. It is also disputable whether the historical and cultural differences between the researchers’ and the participants/the setting influenced the outcome: The history of being colonized by “the whites”, the British, might have affected both what the researcher saw and heard amongst the participants and also how the researchers analyzed the gathered
information.
The aim of the study was researched using NANDA and NIC. These taxonomies were used when analyzing the observations and as coding manuals to establish nursing diagnoses and interventions. A coding manual contains instructions through viewing all the appropriate dimensions and the categories within these dimensions (Bryman, 2011). This notion was utilized when categorizing the observations according to NANDA categories. The interventions were also categorized with a NANDA category as a prefix (see table 3). The actual codes in the analysis are NANDA diagnoses and interventions. The relationship between NANDA and NIC were studied using NANDA, NIC and
NOC Linkages, edited by Johnson (2005) and Nursing Diagnosis Application to Clinical Practice by Carpenito-Moyet (2010). This nursing literature defines
physiological and psychological clinical findings to support certain nursing diagnoses or actions that are perceived as nursing interventions. NANDA and NIC are viewed as belonging together in the mentioned nursing literature but were not always clarified as belonging together in the observations. Bryman (2011) discusses the various pitfalls of using a coding manual. To avoid one of these pitfalls it is recommended to test the coding manual in a pilot study. Perhaps this would have created a different result or a more clarified relationship between the nursing interventions and diagnoses in the result. NANDA and NIC are viewed as standardized nursing language. Nursing and
academic care plans need to be transformed into a clinically useful product. In doing this, assessment criteria and specific interventions need to be organized in a nursing clinical practice outline (Carpenito-Moyet, 2010). Further, Carpenito-Moyet argues that “the nursing is defined by what we do and what we write, not by what we know” (page xi).
The effect of standardized nursing language on the nurses’ autonomy has been debated; critics regard it as threatening towards the autonomy of the nurse, due to the use of electronic storage of health information. Standardized nursing language has become a mean to describe the nurses’ contribution and their use of clinical knowledge; the evaluation of their own practice and a way to define the continuity of care to patients and between themselves (Mrayyam, 2005). The International Classification of Nursing
Practice (ICNP) is current in defining and updating the use of standardized language in
nursing practice. The objective is to establish a common language describing the nursing practice to provide nursing practice data across a variety of clinical settings (ICN, 2011). The three defining elements of the ICNP are the focus of nursing (nursing diagnoses), the actions of nursing (nursing interventions) and the results of nursing (nursing outcome) (ICN, 2011). Leininger (2002) thinks of NANDA as culture
insensitive, leading to faulty diagnoses of problems. Diagnoses represent responses that clients and families find problematic from their perspective, cultural or otherwise (Wilkinson, 2007). However, Wilkinson admits that all problems and etiologies are influenced by cultural factors but specifies the differences in, for example, the expression of pain between cultures.
NANDA and NIC were used as evidence based modes of reliability. Pilhammar
Andersson (1996), states that the pre-understanding of the researcher always affects the interpretation of the performed observations. Knowing this, it could be questioned if an participant observation is a well-chosen method. Interviews with the patients would have given a more manifest picture of the nursing care but because of the language barrier, this would have demanded translators of multiple languages. In addition to this, it is questionable how many patients and attendants would accept taking part in
interviews as it would demand precious time and energy from them, something of which they might already be lacking. Since the aim was to identify the nursing panorama of patients with musculoskeletal injuries in the context and habitat of the patients and the staff, the method of participant observations seemed most efficient.
8.2 Result Discussion
The patients accepted by the inclusion criteria were predominantly male. The number of male patients was 19 while only 5 female patients fitted the study design. Previous trauma studies performed in Kampala resulted in a gender distribution of close to 72% male and about 28% female (Kobusingye, Guwatudde & Lett, 2001), which was also the approximate gender distribution at the ward previous to applying the inclusion criteria on our sample.
The aim of the study was to identify the nursing panorama of patients with
musculoskeletal injuries in Uganda. The performance of the attendants was the most striking aspect of the nursing panorama and the most culturally different perspective in comparison to the cultural background of the observer. In our study, we found that the facilitation of nursing diagnoses and interventions was performed by both the
attendants and hospital staff. According to Åstedt-Kurki, Paunonen and Lehti (1997), the care of a family member reflects the wellbeing of all members of the family. Attendants in the Swedish care scenario have the approach of controlling the wellbeing of the sick family member rather than controlling the nursing (Åstedt-Kurki Paunonen & Lehti, 1997). Our study exposed attendants not only controlling the wellbeing of the patient but actually complementing the nursing, primarily with self-care deficits, nutrition and comfort, but also with active advice and resolution when the staff nursing was deficient or hospital supplies were low. The policy towards attendants at Mulago Hospital has similarities with historical Swedish policies regarding the care and nursing responsibility. It was not until the 1980s that the Swedish society expressed the health care responsibility for its population (Johansson, 2007). In contrast to our findings regarding attendants’ responsibility, previous studies found that the relatives to
orthopedic patients were less effective than nurses when helping patients in and out of bed or exercising (Mrrayan, 2005). On the other hand, nurses in our study were verbally efficient towards patients even when being abusive.
As the aim of the study was to describe the nursing panorama using NANDA and NIC, little focus was placed on diagnoses and interventions outside the NANDA and NIC taxonomies. However, findings were made concerning the behavior of the staff which
led to the non NANDA diagnosis risk for injury:staff. This depicted staff acting on their own negative perception of their tasks. According to Thompson and Cechanovicz (2007), the profession of the nurse creates a hierarchy gap to most Ugandan patients with elements of paternalism in the health care environment. The austere approach to patients creates a limited professional outcome for the nurses and diminishes the role of the nurses to administrative tasks like medication- or treatment procedures. This
supports our finding as the most common intervention executed by nurses in our study was medication management. Within a study performed on trauma and orthopedic patients in multiple European countries, it was concluded that nurses also neglect individualized care which is especially important with orthopedic patients as the performance of self-care indicates the health outcome of the patient (deSouza, 2002).
The choice to use NANDA and NIC was due to the fact that NANDA is starting to appear in Swedish health care settings and that NIC is the traditional compliment to NANDA. There are other taxonomies or systems that could have given a different result. American Nurses Association has recognized the following nursing
classification systems: NANDA, The Omaha System, the Home Health Care
Classification, NIC, the Nursing Outcomes Classification and the Patient Care Data Set. The Omaha- and the Home Health Care Classification system were developed to be applied within home care and would not have been accurate for inpatient care (Hyun & Park 2002). The Patient Care Data Set is described as a computerized health care record (Daly, Maas & Johnson, 1997), and was therefore excluded as a tool for our study primarily because the observed journals in our study were written by hand and were archived without the use of computers. The Swedish tradition of nursing diagnoses is scarce, although nurses are required by law to document nursing care and include nursing diagnoses. The Swedish nurses tend to formulate nursing diagnoses with their own choice of words (Axelsson, Björvell, Mattiasson & Randers, 2006).
It was, for practical reasons, decided to exclude Nursing Outcomes Classification and only use NANDA and NIC in the study. In 2003 the NANDA, NIC and Nursing Outcomes Classification were published as a unifying structure in the form of the
Taxonomy of Nursing Practice. Nursing Outcomes Classification is a classification of
interventions, and thus, Nursing Outcomes Classification is the goal met with the nursing interventions and preceding nursing diagnosis (Johnsson, 2005).
The interventions were sometimes restrained due to shortage of equipment or hospital financial rules. Different turnouts were observed regarding different patients with similar problems. One patient was allowed x-ray and home transport, financed by the hospital while other patients were not met with the same resources. Thompson and Cechanovicz (2007) observed the same inconsistency in a Ugandan health care setting, similar to Mulago Hospital, and blame the inconsistency of supplies and medications in Uganda on corruption. The inconsistent variation and the span of interventions were enhanced by the attendants who surrounded the observed patient. An example of this is the two patients who were admitted without attendants, where only one was able to borrow another patients’ attendant. Thompson and Cechanovicz (2007) state that the aspect of caring is based on cultural motives. They prescribe solidarity and kinship based on tribal norms, alliances and/or different languages.
The diagnostic findings in the result differed in detail from earlier studies but were similar in general. According to Thoroddsen and Thorsteinsson (2002), the most common acute setting diagnoses were altered comfort, self-care deficit, impaired
physical mobility and emotional discomfort. They claim that the setting of diagnoses
depend on experience, knowledge and tradition. They also state not classified nursing diagnoses in high frequency. Our result had only one unclassified nursing diagnosis, primarily due to the aim of the study to be acquired using classified nursing diagnoses and interventions. Self-care deficit were very common in our study; dressing- and toileting self-care deficit were among the top ten most common diagnoses. However
altered comfort were not used as this diagnosis were towered by acute pain. Emotional
discomfort should, in retrospect have been used in a larger extent. Upon observation patients expressed pain but often without complaint. This behavior is explained by Nabirye, Brown, Pryor and Maples (2011) who stipulate that patients fear that health staff will refrain from helping if the patients make too much noise. During the
observations, staff member D. Mbatudde (personal communication, October 4, 2011) explained that it was possible to judge the cultural background of the patient on the level of complaint expressed, but it was unclear which culture that had the tradition of loudly expressing complaint or which patients that were of which culture. According to deWit (2009), the most common nursing diagnoses for patients with musculoskeletal
